Wednesday, November 07, 2007

Why Medical Errors are Good for You

Well, I politely and respectfully disagree. Medical errors, most of them, are NOT prevented and they can't be prevented.

There, I said it. While none of us wants to be the recipient of a medical error, medical errors might just be good for you.

Now before you call the Illinois Department of Regulation and ask that my medical license be revoked, hear me out.

Most of us have heard ad nauseum "that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors." It came from an authoritative and trusted source: the Institute of Medicine's November 1999 report entitled "To Err Is Human: Building A Safer Health System." Clearly, there is a political motive to reduce these errors and certainly, if even one death can be prevented, that is a good thing.

But the Institute of Medicine never examined the number of errors ultimately prevented by institutions reviewing the circumstances that surrounded each of these deaths. Medicine, after all, will never be "perfect" in preserving the sanctity of life since life is never limitless. Unfortunately, medicine has been so erroneously marketed as infallible and full of limitless potential to preserve life, that the media, including our own authoritative WebMD, feel that medical errors are "now a 'leading cause' of death and disability."

But medical errors serve as an invaluable resource and irreplaceable learning tool for our housestaff, physician attendings and nurses. For instance, most medical school and hospital medical and surgical programs are required to have "Morbidity and Mortality" conferences as part of their ongoing training curricula. Here, surgical mistakes and deaths are reviewed critically by scores of those involved in a patient's care. To avoid total humiliation, the responsible doctor usually reviews the literature about the problem that occurred and summarizes the case and its relevancy to that literature. Often the doctor is coarsely questioned by his colleagues, often to his embarrassment to be sure, but also to the benefit of scores of other physicians watching and listening to the conference. The beneficial amplification factor of a single medical error, in this instance, in terms of training and ultimately avoiding further errors, might be 100 to 1. In other words, in the ideal setting, 100 future errors might be prevented because the one error was reviewed critically with 100 other people.

Autopsies are another valuable and irrevocable teaching aide, but sadly, are rarely performed any more. A myriad of questions arise in the course of a complicated and challenging illness - particularly when maladies befall an individual after a single medical error. The opportunity to understand the cause of illness or consequences of our actions proves invaluable to score of others involved in a single patient's fatal medical error. Without reviewing, without examining critically or foibles as human beings, we will never improve our "practice" of medicine.

I look back at errors I have made in the past and how they have influenced the way I perform procedures. In my early electrophysiology career, I would always perform a subclavian approach (in the upper chest) or internal jugular approach (in the neck) for placing an electrophysiology wire into the coronary sinus (the main cardiac vein that returns blood from the heart to the right atrium). Anatomically, I felt in the past, it was easier to gain access to the coronary sinus from these superior approaches. And that was how I was taught. But long ago, I had a pneumothorax, a punctured lung, from trying to gain access to the subclavian vein. I had explained to the patient beforehand that this might happen, but I still felt horrible that the "error" had occurred. I lost countless hours of sleep worried that the patient would not recover. (They ultimately did fine). But what did I learn? I learned that I better check the x-ray after such a procedure. I learned that if there was another way to avoid this complication, I would like to learn it. I later learned how to place coronary sinus catheters from the leg while observing others in a different clinical setting. As such, I have never had a pneumothorax from a routine electrophysiology since and no longer require chest x-rays following these procedures as a result.

Was this error useful? Absolutely. I would even say it was critical to shaping my clinical approach for hundreds of other patients. Errors, as difficult and as unfortunate as they may be, remain critical to our development as doctors. Although no one wants them to occur, they do have benefits to developing a mature perspective and technique to medical practice. Critical review of inevitable medical errors should remain a critical part of our medical school curricula.

After all, how will we really learn?

What I tell my medical students, residents, and fellows is this: it's okay to have a medical error once, just never make the same error twice.

My point is not to condone making errors, but rather to understand that they will happen, irrespective of all of the safety measures in place. People's anatomies are different, doctor's clinical skill levels are different, and a myriad of other inter-dependent variables (pharmacists, nurses, nurse's aides, transporters, technicians, medications, therapies, etc) create an nearly infinite interplay that can lead to medical errors.

We must accept that these errors can and will occur and then use the experience gained by these unfortunate errors to prevent future ones.

Your example was of a non-preventable error. If you clarify the scope of your article to just non-preventable error, it makes sense. However you must acknowledge based on a growing body of knowledge that many medical errors are preventable, e.g. wrong site surgery, medication errors, etc. There are mainstream error-proofing methods that are applicable to these types of problems, e.g. bar-coding, RFID and protocols like time outs for team review prior to surgery, etc. that are also being used with success. You should do more research on this.

I know you meant to focus on the ways doctors can and should learn from errors. But I have to be honest and say that this piece comes off as just another doctor justifying the way things are, and seems to suggest that we should lower our expectations of medicine, because after all, sh*t happens. I'm sorry, but what we should be talking about is (to borrow a phrase) "the relentless pursuit of perfection". Not simply learning from inevitable errors.

Many, many technologies have been required to keep up with the dizzying array of complexities inherent to the healthcare system of today, as you have pointed out. Certainly, many of these measures have saved countless lives. But why were these technologies born? It's because others were less fortunate and had an error occur, it was reviewed, and mechanisms developed to avoid them in the future. But too often, we have ignored errors "assuming" we know the answer, when in fact, the answer was left "on the table." Take these data regarding autopsy rates:

"Nationally, autopsy rates have declined from 50% in the 1940s to a discouraging 14% in 1985. Autopsy rates in non-teaching hospitals are now less than 9%. Moreover, fewer autopsy reports reach clinicians in a timely way, which, along with the concomitant decline in M&MC, inevitably reduces the educational value of the autopsy and downplays its role as a tool for professional improvement. In 1995, the National Center for Health Statistics even stopped collecting autopsy data altogether."

Might we be missing other valuable lessons?

Anony 11:55 -

As the Institute of Medicine's report was entitled: "To Err is Human...", while the pursuit of "perfection" is a laudible goal, can it ever be achieved? How many dollars and regulation should we apply to this goal? Certainly a huge cottage industry of quality assurance committees, regulations, and companies stand ready to make "sure" we achieve that goal. And yet, less and less we fail to devote the time and energy to review the errors that DO occur.

Dollars and regulation are NOT the answer, nor was I suggesting that. You cannot monitor your way to perfection.

Let me put it simply. Do you want to go to a doctor that says, "well, perfection is impossible, so I aim for pretty good"? Or do you want a doctor or a hospital that is constantly learning, constantly trying to improve systems, training, education, etc in order to achieve better and better performance. Yes learning from errors is critical. Clearly some places/people are better than others at learning from mistakes. What makes those places different? That's what I mean by the pursuit of perfection. The latest quality talk is of setting goals for hospitals of ZERO hospital acquired infections etc. Perfection must be considered possible. Annika Sorenstam (pro golfer) has designed her entire game around the theory that a 54 is possible - birdie every hole. That's the kind of thinking I want to see in medicine.

Let me put it simply. Do you want to go to a doctor that says, "well, perfection is impossible, so I aim for pretty good"?

yes, this is the doctor i'm looking for bc he is rooted in reality and isn't sugar coating things for me by telling me he is perfect and never makes mistakes.

'Perfection must be considered possible.' agreed, however, only if we're talking about robots. humans get tired, humans get distracted, and humans make mistakes - that's what separates man from god.

also, as to your analogy of Annika - she's a golfer and it seems a stretch to compare the pressure a doctor feels in caring for the life of another to that of someone playing a game. granted you are trying to make a point that she strives for perfection, but comparing the pursuit of perfection in a game vs the life-and-death care of another is off-base. during her pursuit of perfection, if annika makes a mistake, she goes goes down a stroke; during a doctor's pursuit of perfection, if he makes a mistake someone dies or he gets sued and put out of business.

finally, my guess is that you're not a doctor, but regardless of profession i ask - have you ever made a mistake at work? and after acknowledging your mistake, and striving for perfection, have you ever made another?

Josh - Your points are well taken. Another saying (learned from a physician appropriatly enough) is that "perfect is the enemy of good".

You are right, I'm not a physician, or even a clinician. A point I try to be sensitive to. But I work in healthcare with physicians on a regular basis. My expectations for medicine are high, maybe too high. But we're not making widgets here. As you point out we are talking about actions with serious implications. I have a great deal of respect for what physicians have to deal with. On the other hand I witness a tremendous amount of resistance to improvement and a lack of appreciation for the healthcare experience as a whole - not just the piece the physician sees. My experience is that to physicians, high quality is "the medicine I practice in my office". There is very little appreciation for the systems, structures, and processes that constitute the whole of the healthcare experience, not to mention issues of continuity of care or coordination of care. The gap between what we know constitutes best practice and what is practiced every day is large.

Yes we need to learn from errors. No question. My point I guess is that rather than thinking of errors as inevitable and feeling good about learning from mistakes after they happen, we should be constantly striving to keep them from happening in the first place.

i guess in a nutshell, i'd say that i agree that we should constantly be in pursuit of perfection (regardless of occupation); however, when taking human nature into account, it becomes apparent that some strive for perfection and learn from their errors (i believe this is the pt dr. wes was trying to make) while others learn nothing and continue to make errors (the bone of your contention).

i think we are all on the same page with this one: that errors are not great and should be avoided, but when they can't be avoided, it is through errors that learning takes place - something that holds true from birth to death.

Nice site - reasoned & inquisitive! I would submit that your pneumo was a known complication and NOT an error, just like a dural puncture during an epidural placement. If there's a way to improve a particular procedure by changing or adding(ultrasound for example), then kudos to the doc - they're practicing the art of medicine.

In training and in practice, most physicians do the best they can. No other profession can make that claim. We can't "phone in" a game, a brief, or a film while commanding huge sums of money. Unless there's a screw loose, the vast majority of MD's treat patients like family, with an escalating amount of effort when the risks and stakes are even higher. I suppose if the demand towards perfection increase too much, you'll see MD's simply decline to the the risk. Is that what we want? Medicine is not a faster, faster, more, more field of work. Would you rush a typesetter, watchmaker, parachute folder?Physicians know the dictum, "The enemy of good is better". They also know when or when not to apply it.MFlynnMD

I find this entry and the comments very interesting. I recently left active duty as an infantry officer, and there are definite analogies between medical errors, and some of the measures taken to prevent them, and the methods we used to reduce soldier deaths from both accidental and intentional (i.e. enemy) sources.

The problem is similar in many ways. In both professions, you have to take some level of risk to accomplish anything. The morbidity and mortality seminars have some similarities to after action reviews we did after serious injuries and deaths. Some soldier deaths are preventable, some non-preventable, and some can become preventable if we look at them carefully and learn the right lessons.

However, in the Army we had a risk management process. It did not necessarily dictate doing everything the same way every time (it depended on the action - for example, there's only one right way to remove the transmission from a tank), but it established a common set of expectations for how leaders would identify risk, develop controls, assign responsibility, implement the controls, supervise, and then re-assess.

If something like that exists in the medical profession, it needs to be better publicized. My perception - and I am only slightly better informed than average on this - is that some organizations take a systematic approach to risk management and others don't. So either there needs to be a more systematic approach across the profession and industry, or the approach(es) that exist need to be communicated more effectively.

Thank you for bringing up this issue and sponsoring such a thoughtful discussion.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.